Make a claim Please select the type of policy you wish to make a claim against. Once completed, one of our claims team will get back to you as soon as possible. Please select a policy type* Personal Business Please select the claim type* Property Claim Motor Vehicle Claim Motor Vehicle ClaimInsured Name* Policy NumberContact*PhoneEmail* Registered for GST Yes No Input Tax Credit entitlement on premium*Input Tax Credit entitlement on property damaged*Was the vehicle being used for* Business Use Private Use Property Claim FormInsured Name* Policy NumberContact*PhoneEmail* Registered for GST Yes No Input Tax Credit entitlement on premium*Input Tax Credit entitlement on property damaged*When did the loss, theft or damage occur?* MM slash DD slash YYYY Time* : Hours Minutes AM PM Which is: Occupied by the insured Unoccupied / Vacant A holiday home Please describe what happened*Vehicle DetailsYear* Make* Rego* Model* Is there any finance owing on the vehicle?* Yes No Are you claiming damage for the vehicle?* Yes No Detailed description of the damageWas the vehicle towed?* Yes No Has a repair quote been obtained?* Yes No What is the current location of the vehicle?* Preferred repairer details* Incident DetailsDate:* MM slash DD slash YYYY Time:* : HH MM AM PM Location (street/suburb)* Please describe what happened in the accident and why it occured. e.g. speed, traffic lights, weather:*Who does the driver consider is at fault and why?*Drivers DetailsName* Contact Phone Date of Birth:* MM slash DD slash YYYY Licence No Expiry Date* Year Licensed* Licence Type Learners Probationary Full Class Did the driver consume alcohol/drugs/medication in the 12 hours prior to the accident?* Yes No Had insurance declined, cancelled or special conditions imposed in the last 5 years?* Yes No Convicted of or had any fines or penalties imposed for any criminal offence?* Yes No Had an accident or made a claim on a motor insurance policy in the last 5 years?* Yes No If YES to any of the above, please provide details*Third Party DetailsThird Party Details Name* Contact Phone Address* Insurance Company* Policy/Claim No Rego* Licence No Year* Make* Model* Detailed description of the damage*Police Details (Name/Station/Police Report No.)Police Details (Name/Station/Police Report No.)*Witness DetailsWitness Details*Additional DetailsAdditional Information*Incident DetailsANY LOSS INVOLVING MALICIOUS DAMAGE, LOST OR STOLEN PROPERTY MUST BE REPORTED TO THE POLICEWere the premises occupied at time of loss?* Yes No If no, date last occupied* MM slash DD slash YYYY Time* : HH MM AM PM Do you know who is responsible for the loss, theft or damage? Yes No Name Address Please detail what has been lost/stolen/damaged and estimate value to repair/replaceParticularsAmount Claimed Fusion/Power Surge ClaimsAge of Motor Is the motor under warranty? Yes No Burglary ClaimHow was the building entered? Available security to premises: Give details of any security improvements taken since the loss:PoliceStation Report Number Date Reported MM slash DD slash YYYY Reporting Officer If your insurer approves a cash settlement, would you like funds deposited into your bank account? Yes No Bank BSB Account Name Account Number HistoryHad insurance declined, cancelled or special conditions imposed in the last 5 years? Yes No Convicted of or had any fines or penalties imposed for any criminal offence? Yes No Had an accident or made a claim on a motor insurance policy in the last 5 years? Yes No If YES to any of the above, please provide detailsDeclarationDo you agree to the declarations* I agree By submission of this claim for, you acknowledge and accept the following Declarations Privacy The Privacy Act and the Australian Privacy Principles require your insurer to tell you that they collect your personal and sensitive information in order to calculate your loss and entitlements, determine their liability, compile data and handle claims. When handling claims, they may have to disclose your personal and other information to Insurance Reference Services (IRS), etc. or other parties as required by law. By reading and acknowledging the Adroit privacy collection notice you consent for us to proceed with submitting this information to your insurer. You have to right to seek access to your personal information and to correct it at any time. Please contact us on (03) 5244 7813, 8:45am - 5:15pm, Mon-Fri and advise the changes. Declaration I/We certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I/We understand that this claim may be refused if information is untrue, inaccurate or concealed. I/We acknowledge that I/We have read and understood the privacy information of all persons affected by this claim. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information then the Insurer will be unable to process my/our claim.